(combination of multiple documents)
1. Workplace
2. Patient
3. Anaesthetist
4. Root cause analysis
Replacement |
· Anaesthetist ceases clinical duties · Call in a relief anaesthetist |
Isolation |
· Leave the scene untouched · Move the list to another operating theatre |
Notifications |
· Hospital co-ordinator · Hospital insurers · ±Coroner |
Documentation |
· Draft before final copy · Show to anaesthetist ± his/her MDO · Facts only · No opinions · No speculation regarding the cause · DO NOT ALTER THE ANAESTHETIC RECORD |
a.Preparation:
Plan |
· Arrange meeting without delay · Rehearse your lines |
People |
· Patient/relatives ± support person · Anaesthetist ± support person · Proceduralist · Junior doctor (for documentation + learning) |
Place |
· Private room · Chairs · All on the same level |
b.Discussion:
Introduction |
· Introduce your team · Confirm identity of those attending |
Assessment |
· Ask what they know already · Consider level of understanding |
Tell |
· Fire a warning shot · Small pieces of information · Frequent pauses · Facts only · No jargon · Sympathy but not blame |
Listen |
· Allow time to process · Acknowledge emotional response · Allow questions |
Summarise |
· Say it again in 20 words · Offer further contact · Offer referral serves |
Risks |
· Dysfunctional behaviour · Adjustment disorder · PTSD · Early retirement · Substance abuse · Suicide |
Supports |
· Family · Peers · Mentor · GP · Psychologist · Psychiatrist · Dedicated service: e.g. hospital EAP, ANZCA DSP, DHAS |
Personal responsibility |
· Do not return to work until recovered |
Department responsibility |
· Confidentiality · Provide trained support person (usually a psychologist) · No use having a judgemental culture |
· Formal review by hospital committee
Summary of responsibilities:
Patient/family |
· Patient care · Open disclosure |
Anaesthetist |
· Ring MDO · Self-care (second victim) |
Team |
· Optional debrief · Offer to send home |
Department |
· Notify HOD at the time · M&M later |
Hospital |
· Notify AHC at the time · Root cause analysis later |